Prognostic factors of nasopharyngeal carcinoma: a multivariate analysis

Prognostic Value of Volume-Based Positron Emission Tomography/Computed Tomography in Nasopharyngeal Carcinoma Patients after Comprehensive Therapy

Objective

We assessed the prognostic value of standardized uptake value (SUV) and volume-based methods including whole-body metabolic tumor volume (WBMTV) and whole-body total lesion glycolysis (WBTLG) using ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) of patients with nasopharyngeal carcinoma (NPC) after therapy.

Methods

A total of 221 posttherapy NPC cases were enrolled, all of whom had undergone PET/CT scanning and follow-up in this retrospective study. The diagnostic results of PET/CT were analyzed and compared with histopathological diagnosis or clinical follow-up. Receiver operator characteristic curves, the Kaplan-Meier method, and the log-rank test were used to assess the optimal cutoff values for WBMTV and WBTLG to identify independent predictors of survival.

Results

The detection rates of the threshold SUV were 2.5, 20%, and 40%, and SUV background methods were 65.6% (378/576), 80.2% (462/576), 71.5% (412/576), and 90.4% (521/576), respectively (P < 0.005). Patients with a WBMTV < 8.10 and/or a WBTLG < 35.58 had significantly better 5-year overall survival than those above the cutoffs (90.7% versus 51.2%, P < 0.001; 91.7% versus 50.4%, P < 0.001), respectively. Multivariate Cox regression modeling showed both WBTLG (RR, 1.002; P = 0.004) and age (RR, 1.046; P = 0.006) could be used to predict overall survival. WBTLG (RR, 1.003; P < 0.001) may have predictive relevance in estimating disease-free survival.

Conclusions

SUV volume-based threshold background methodology had a significantly higher detection rate for metastatic lesions. WBTLG could be used as an independent prognostic indicator for posttherapy NPC.

Prognostic Significance of Standardized Uptake Value on 18Fluorine-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Patients with Nasopharyngeal Carcinoma

The aim of this study was to investigate the prognostic significance of standardized uptake value (SUV) on 18 fluorine-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma (NPC). Thirty-four patients who have histologically proven NPC and underwent ¹⁸F-FDG PET/CT were included in this study. After ¹⁸F-FDG PET/CT, all the patients received radiation therapy and 32 of them received concomitant weekly chemotherapy. The maximum SUV (SUV_max) at the primary tumor and the SUV_maxof the highest neck nodes were determined. The SUV_max-T ranged from 5.00 to 30.80 (mean: 15.37 ± 6.10) and there was no difference between SUV_max-T values for early and late stages (P = 0.99). The SUV_max-N ranged from 3.10 to 23.80 (mean: 13.23 ± 5.76). There was no correlation between SUV_max-T and SUV_max-N (r = 0.111, P = 0.532). There was no difference between the SUV_max-T and the positivity of neck lymph nodes (P = 0.169). The ability of SUV_maks-N to predict stage was obtained by a receiver operating characteristic (ROC) analysis. The area under the curve is 0.856 and the best cut-off value is 7.88. There was a good correlation between SUV_max-N and stage. While the mean SUV_max-T for the alive patients was slightly lower than that for the dead (14.65 ± 5.58 vs. 20.30 ± 7.92, P = 0.061), the difference between the groups was not statistically significant. Furthermore, there was no statistically significant difference for SUV_max-N between these two groups (P: 0.494). Cox-regression analysis showed that an increase in SUV_max-T and SUV_max-N was associated with death risk (relative risk [RR]: 1.13, P = 0.078 and RR: 1.052, P = 0.456, respectively). SUV_max-T and SUV_max-N were independent prognostic factors for survival in NPC patients. This will help the clinicians in choosing suitable candidates for more aggressive treatment modalities.

Retrograde analysis of clinical characteristics of bone metastasis in 1,031 cases of preliminarily diagnosed nasopharyngeal carcinoma

PURPOSE

To explore the clinical characteristics of bone metastasis (BM) in a large sample of preliminarily diagnosed nasopharyngeal carcinomas (NPCs).

METHODS

The sample consisted of 1,031 patients diagnosed with NPC at first visitg clinics between October 1989 and June 2012. Several parameters including metastasis locus, T/N staging, diagnosis, therapy and prognosis of BM were analyzed retrospectively.

RESULTS

In 70 patients who had been preliminarily diagnosed with BM, the incidence of BM in N0, N1, N2 and N3 stage was 5.7%, 17.2%, 50.2%, and 25.7%, respectively, while the incidence in T0, T1, T2 and T3 stage was 0%, 23.8%, 47.6% and 28.6% respectively. BM occurred in most common in vertebral column, rib, sternum, ilium and femur. Positive rate of Epstein-Barr virus antibody was 77.6%. The median survival time was 12 months.

CONCLUSION

The incidence of BM in NPC preliminarily diagnosed is about 7% and it is related to N classification but not T classification.

Role of chemotherapy in stage IIb nasopharyngeal carcinoma

The efficacy of neoadjuvant chemotherapy and adjuvant chemotherapy on stage IIb nasopharyngeal carcinoma (NPC) remains unclear. Conventional two-dimensional radiotherapy combined with concurrent chemotherapy can improve the overall survival, progression-free survival, recurrence-free survival, and distant metastasis-free survival of patients with stage IIb NPC. Intensity-modulated radiotherapy without concurrent chemotherapy also provides good outcomes for patients with stage IIb NPC. This article summarizes the features of stage IIb NPC and reviews the role of chemotherapy in this subgroup of NPC.

Salvage surgery for neck residue or recurrence of nasopharyngeal carcinoma: a 10-year experience

BACKGROUND

To assess the outcome of and determine prognostic factors for neck residue or recurrence of nasopharyngeal carcinoma (NPC) in patients treated with a salvage neck dissection.

MATERIALS AND METHODS

Over a 10-year period (from January 1998 through December 2007) in a tertiary hospital, we systematically reviewed the clinical charts of 355 patients with NPC who were diagnosed with neck residue or recurrence of nasopharyngeal carcinoma, after radical definitive radiotherapy with or without chemotherapy.

RESULTS

The group with recurrent nodal disease consisted of 285 patients (80.3%), while the group with residual nodal disease included 70 patients (19.7%). There were no patients died of the surgery complications. Overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) were 54.11, 35.01, and 55.59%, respectively, at 3-year, and 26.03, 22.65, and 27.84%, respectively, at 5-year. The local control rate in the neck was 70.92% at 3 years and 60.98% at 5 years. For all the 3 survival outcomes (OS, DFS, and DSS) and the local control rate of disease in the neck, there were significant differences between the "residue group" and "recurrence group."

CONCLUSIONS

Radical neck dissection is proven to be safe and effective in the treatment of the neck failure. Our study has demonstrated that it may be possible to choose the selective lymph node dissection for patients of the residue group.

Dose Escalation for Patients With Locally Advanced Nasopharyngeal Carcinoma Treated With Radiotherapy Alone

OBJECTIVES

The local control of patients with locally advanced nasopharyngeal carcinoma is still unsatisfactory. This prospective study was designed to evaluate the treatment outcomes and treatment-related complications of patients with locally advanced nasopharyngeal carcinoma treated with escalated radiation doses.

METHODS

A total of 118 consecutive patients with T4 classification (1992 American Joint Committee on Cancer staging system), histology-proven nonmetastatic nasopharyngeal carcinoma were treated with radiotherapy alone between 1992 and 1997 in a medical center in southern Taiwan. Thirty-two of them were enrolled into a prospective study of dose escalation and were irradiated to a total of 81 Gy. The other 86 patients received a total of 70.2 Gy. Potentially significant patient-related and treatment-related parameters were analyzed for their prognostic significance. Radiation-related complications were recorded and analyzed.

RESULTS

The 5-year local progression-free rates were 61%, and 61% for patients receiving 70.2 Gy and 81 Gy, respectively (P > 0.05). The incidences of xerostomia, hearing impairment, and temporal radionecrosis were significantly higher for those receiving 81 Gy. The 5-year complication-free rates of patients receiving 70.2 Gy and 81 Gy were 14% versus 2% for xerostomia (P = 0.0070), 50% versus 30% for hearing impairment (P = 0.0198), and 91% versus 82% for temporal radionecrosis (P = 0.0400).

CONCLUSIONS

For patients with locally advanced nasopharyngeal carcinoma treated with radiotherapy alone, dose escalation to 81 Gy failed to show benefits on local control rate. Higher radiation doses contribute to a higher incidence of radiation-related complications.

Nasopharyngeal carcinoma staging by (18)F-fluorodeoxyglucose positron emission tomography

PURPOSE

Nasopharyngeal carcinoma (NPC) has a high rate of neck lymph node and/or distant metastasis. We evaluated the value of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in staging NPC, especially in the detection of distant metastasis.

METHODS AND MATERIALS

A total of 95 patients, including 85 with primary and 10 with recurrent, NPC were enrolled. Dual-phase FDG-PET was used, in addition to the conventional workup. Eighty-one patients without distant metastases underwent repeat studies 3-4 months after initial radical treatment.

RESULTS

Of 14 patients with distant metastases, all had lesions detected by FDG-PET, and the conventional workup detected the metastases in only 4. Two patients had false-positive MRI findings for neck node metastasis, but the FDG-PET findings were accurate. Four patients without distant metastases on their initial workup were found to have new lesions on FDG-PET 3-4 months after initial treatment. Patients with advanced node disease had a significantly greater incidence of distant metastases on FDG-PET, especially for N3 disease. Of the 95 patients, the FDG-PET results for distant metastasis were true positive in 14 patients, false positive in 8, and true negative in 73. None of our patients had a false-negative result. For a patient base, the sensitivity and specificity of FDG-PET for distant metastasis was 100% and 90.1% (95% confidence interval 81.5-95.6%), respectively, in this study. The accuracy was 91.6% (95% confidence interval 84.1-96.3%), the positive predictive value was 63.6 (95% confidence interval 40.7-82.8%), and the negative predictive value was 100%.

CONCLUSION

FDG-PET stages N and M disease of NPC more accurately and sensitively than does the conventional workup. Patients with advanced node disease, particularly N3 disease, would benefit the most from FDG-PET.

Neoadjuvant chemotherapy plus conventional radiotherapy or accelerated hyperfractionation in stage III and IV nasopharyngeal carcinoma--a phase II study

A prospective phase II trial was initiated in previously untreated patients with locally advanced nasopharyngeal carcinoma (NPC). The goal was to achieve improvement in locoregional control, disease-free interval and overall survival using induction chemotherapy and to compare conventional fractionation (CF) with an accelerated hyperfractionation (AHF) regimen. Fifty patients were treated (5 AJCC Stage III, 45 Stage IV) with induction chemotherapy consisting of two cycles of cisplatin and 5-fluorouracil. Patients were then randomized between CF and AHF therapy. A clinical response to induction chemotherapy was reported in 86% of patients prior to radiotherapy (44% complete response, 42% partial response). Patients with complete or major partial responses to induction chemotherapy had a significantly better 5-year overall survival (60%) and disease-free interval (59%) than those with no response or minor partial response (15% and 18% p = 0.009 and 0.0009). Acute radiation reactions were more pronounced in the AHF group (p = 0.0002), and the incidence of late normal tissue injury was more frequent (p = 0.08). At 5 years, the locoregional control rate was higher in the AHF arm (76%) than in the CF group (54%), but the difference was not significant (HR, 0.52; 95%, Cl, 0.15-2.83; p = 0.186). With a median follow-up period of 55 months (range 4-120), the 5-year disease-free interval and overall survival rates were more favorable in the AHF group than in the CF group, but the differences were not significant (59% and 54% vs. 34% and 36%, respectively, HR for disease-free interval = 0.71; 95% CI, 0.27-1.88; p=0.198 and HR for overall survival = 0.81; 95% CI, 0.37-1.78; p=0.433). The overall treatment failure rate was 48%. Locoregional failures occurred in 12 patients (24%) and the incidence of distant metastases reached 30%. Response to induction chemotherapy is strongly predictive for locoregional control, disease-free interval and overall survival. Accelerated hyperfractionation was associated with high incidence of acute and late toxicity without significant improvement in locoregional control rate. The optimal chemotherapy dose and sequencing with radiotherapy needs to be investigated in future studies. Distant metastases remain the main cause of treatment failure in NPC.

Nasopharyngeal carcinomas: analysis of patient, tumor and treatment characteristics determining outcome

PURPOSE

The present study reviews the experience in treatment of 447 patients with nasopharyngeal carcinomas, analyzing patient, tumor and treatment characteristics determining outcome.

MATERIALS AND METHODS

There were 322 males and 125 females, their ages ranging from 7 to 85 years (median, 45 years). Two-hundred and seventy-two patients had World Health Organization (WHO) type 3 carcinomas, 123 patients had T4 tumors and 320 patients had metastatic cervical lymph nodes. Three-hundred and eight patients were treated with radiation therapy alone and 139 patients with chemotherapy in combination with radiation therapy. Cumulative radiation dose to primary tumor ranged from 50 to 76Gy (median, 70Gy) and radiation dose to metastatic cervical lymph nodes ranged from 46 to 74Gy (median, 66Gy).

RESULTS

Follow-up ranged from 0.1 to 19.5 years (mean, 7.6 years). Local complete response was achieved in 357 patients. In multivariate analysis, T-classification, cumulative radiation dose to primary tumor and treatment with chemotherapy in combination with radiation therapy predicted local response. Nodal complete response was achieved in 272 patients. In multivariate analysis, N-classification and radiation dose to metastatic cervical lymph nodes predicted nodal response. Local failure was observed in 70 patients, nodal failure in 35 patients and systemic failure in 114 patients. Overall survival, disease-free survival and disease-specific survival were 33, 32 and 37%, respectively, at 10 years. In multivariate analysis, age, T-classification, N-classification, radiation dose and treatment with chemotherapy in combination with radiation therapy predicted overall survival whereas T-classification, N-classification, radiation dose and treatment with chemotherapy in combination with radiation therapy predicted both disease-free survival and disease-specific survival.

CONCLUSIONS

Radiation therapy alone appears to be an adequate and viable treatment for patients with early-stage nasopharyngeal carcinomas, whereas treatment with chemotherapy in combination with radiation therapy appears to improve outcome for patients with advanced-stage nasopharyngeal carcinomas.

Important prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma after radiotherapy

PURPOSE

To evaluate the long-term outcome and prognostic factors in patients with skull base erosion from nasopharyngeal carcinoma after initial radiotherapy (RT).

METHODS AND MATERIALS

From January 1985 to December 1986, 100 patients (71 males, 29 females) with a diagnosis of nasopharyngeal carcinoma were found on computed tomography (CT) to have skull base erosion. The mean age was 41 years (range 16-66). Ninety-six patients had World Health Organization type III undifferentiated carcinoma, and 4 had type I. The metastatic workup, including chest radiography, liver ultrasound scanning, and liver function test was negative. All patients underwent external beam RT (EBRT) alone to 66-80 Gy during 6-8 weeks. A daily fraction size of 2 Gy was delivered using 60Co or a linear accelerator. No patient received chemotherapy. All patients were followed at regular intervals after irradiation. The median follow-up was 22.3 months (range 2-174). Survival of the cohort was computed by the Kaplan-Meier method. The potential prognostic factors of survival were examined. Multivariate analyses were performed using the Cox regression model.

RESULTS

The 1, 2, 5, and 10-year overall survival rate for the cohort was 79%, 41%, 27%, and 13%, respectively. However, the subgroup of patients with both anterior cranial nerve (I-VIII) and posterior cranial nerve (IX-XII) involvement had a 5-year survival of only 7.7%. A difference in the time course of local recurrence and distant metastasis was observed. Both local recurrence and distant metastasis often occurred within the first 2 years after RT. However, local relapse continued to occur after 5 years. In contrast, no additional distant metastases were found after 5 years. The causes of death included local recurrence (n = 59), distant metastasis (n = 21), both local recurrence and distant metastasis (n = 1), and unrelated causes (n = 5). After multivariate analysis, complete recovery of cranial nerve involvement, cranial nerve palsy, and headache after irradiation were found to be independent prognostic factors in this cohort.

CONCLUSIONS

We present one of the longest follow-ups of patients with nasopharyngeal carcinoma invading the skull base. Our results demonstrate the importance of cranial nerve involvement, recovery of headache, and cranial nerve palsy. These factors should be carefully evaluated from the history, physical examination, and imaging studies. A subgroup of patients with skull base involvement had long-term survival after RT alone. The findings of this study are important as a yardstick against which more aggressive strategies, such as combined radiochemotherapy and altered fractionation RT can be compared.

Implications of quantitative tumor and nodal regression rates for nasopharyngeal carcinomas after 45 Gy of radiotherapy

PURPOSE

To quantitatively investigate the clinical implications of tumor regression rate (TRR-45) and nodal regression rate (NRR-45) of nasopharyngeal carcinomas (NPC) after receiving 45 Gy of radiotherapy (RT). The values, predictive values, and associated factors of TRR-45 and NRR-45 in NPC are analyzed.

METHODS AND MATERIALS

One hundred one patients with newly diagnosed NPC and who were curatively treated by RT alone were included in the study. Tumor volume and nodal volume before treatment and after 45 Gy were obtained from computed tomographic (CT) scans performed at those times and calculated with the assistance of a computer-based imaging analyzing system. TRR-45 (NRR-45) was defined as the ratio of reduced tumor (nodal) volume after 45 Gy to the initial tumor (nodal) volume. TRR-45 (NRR-45) values were stratified into three groups of slow (below 50%), moderate (between 50% and 75%), and rapid (above 75%) change. After conventional RT with 45 Gy, conformal RT for primary tumors was boosted to 70.2-72 Gy for T1-2 tumors, and 75.6-81 Gy for T3-T4 tumors. RT for residual neck masses was boosted by electron beam to 61-75 Gy.

RESULTS

The mean value of TRR-45 for all patients was lower than that of NRR-45 for the 78 patients with metastatic neck nodes (70% +/- 4.8% vs. 81% +/- 5%, p = 0.003). The 3-year actuarial neck control rate was better than the primary tumor control rate with statistical significance (98% vs. 85%, p = 0.009). No significant statistical differences concerning local control probability, nodal control probability, or survival rate were found among patients with slow, moderate, or rapid TRR-45 or NRR-45. T-stage was the only significant prognostic factor for locoregional control after multivariate analysis. Tumor volume and T-stage were found to have a statistically significant negative correlation with TRR-45. No associated factor was found to be significantly correlated with NRR-45.

CONCLUSION

Slow regression rates of the primary tumor or neck nodes in NPC after receiving 45 Gy of irradiation do not mean ultimately poor radiocurability, but may merely imply slow clearance of the cells damaged during irradiation. The different radiobiological behaviors of the regression rates during treatment, ultimate control probabilities, or associated factors for regression rates of NPC between primary tumors and neck nodes need to be further investigated.

Second malignant tumors in patients with nasopharyngeal carcinoma and their association with Epstein-Barr virus

Since previous published studies about second malignant tumors (SMTs) in nasopharyngeal carcinoma (NPC) patients usually included a limited sample size and did not attain consistent results, we conducted a large retrospective study in a cohort of 1,549 patients to assess the risk of SMT in NPC patients following radiotherapy (RT) in Taiwan. The follow-up period ranged from 2 to 16 years, with a median of 7 years. Thirty-nine patients developed SMTs during the 7,145 person-year follow-up [standardized incidence ratio (SIR): 2. 8; 95% confidence interval (CI): 2.0 to 3.9]. Increased risks of developing SMTs were observed for head and neck (H/N) cancer (SIR: 16.5; 95% CI: 10.0 to 26.8), gastric cancer (SIR: 5.5; 95% CI: 2.2 to 11.4) and leukemia (SIR: 9; 95% CI: 1.9 to 26.3). Paraffin-embedded specimens of secondary H/N cancer (11), secondary gastric cancer (6) and their corresponding NPC specimens were examined by EBER in situ hybridization to assess the association between Epstein-Barr virus (EBV) and these SMTs. Twenty-six primary H/N and 5 gastric cancer specimens were chosen as the control groups. In H/N cancer, EBV was detected in 3.8% of the primary cancers and 9.1% of the secondary cancers. All the positive specimens resulted from hypopharyngeal cancer. Of the secondary gastric cancers, only 1 case (16.6%) was associated with EBV. None of the primary gastric cancers was associated with EBV. Our results indicate an increased risk of developing SMTs, with a preference for head and neck cancer, gastric cancer and leukemia, in NPC patients after RT in Taiwan. Only a small proportion of the secondary H/N and gastric cancers was associated with EBV.

The effect of nodal status on determinants of initial treatment response and patterns of relapse-free survival in nasopharyngeal carcinoma

PURPOSE

To study the effect of regional nodal status on predictors of treatment response, failure patterns, and the time-dependent nature of the various pattern of relapse via a hazard function analysis.

METHODS AND MATERIALS

We reviews tumor control data of 496 patients with nasopharyngeal carcinoma (NPC) to whom a radical course of radiotherapy (RT) with or without induction chemotherapy (CT) was given. All alive patients had a median follow-up period of 131 months. Primary tumor (T) and nodal (N) status were staged according to the TNM system of the American Joint Committee. Remote after-loading brachytherapy may be added to teletherapy in T1-2 lesions while induction CT could be given for N3 and/or T4 lesions. Hazard function analysis over 1-year interval was carried out for locoregional or distant relapse.

RESULTS

T stage and brachytherapy were two independent predictors for complete response (CR) at the primary site irrespective of nodal status, whereas N stage and brachytherapy are major determinants for regional CR in node (+) patients. Multivariate analysis revealed that contributors to a relatively long disease-free interval in (1) node (-) patients were for locoregional relapse, induction CT(-) (p = 0.0062) or brachytherapy (+) (p = 0.0268) and for distant relapse, none; (2) node (+) patients were for locoregional relapse, early T stage (p = 0.0377) or regional CR (p = 0.0075) and for distant relapse, induction CT(-) (p = 0.0001) or regional CR (p = 0.0001). In node (-) or (+) patients, primary CR rate yield no independent prognostic value on various types of disease-free survival. Hazard function analysis for relapse revealed that hazard rates are in general negatively correlated with time, being highest at the first year post-treatment, decreasing from time to time, and approaching zero after a longer follow-up period in patients with locoregional CR than in patients without.

CONCLUSION

Nodal status had no significant impact on predictors of primary CR, whereas in node (+) patients regional CR rate had an independent value in predicting disease-free survival to locoregional and distant relapse. Hazard function analysis revealed a decreasing hazard rate over a protracted post-treatment time in primary and regional CR patients. This indicates the continued risk of late recurrence in this subset of patients for whom long-term observation is recommended.

Locally advanced nasopharyngeal carcinoma: computed tomography findings, clinical evaluation, and treatment outcome

PURPOSE

We present our experience with computed tomography (CT) for delineating the extent of bone erosion in nasopharyngeal carcinoma (NPC) and propose that a new subdivision of Stage T4 disease be added to the staging criteria for cases of minimal bone disease, defined as erosion of the base of the sphenoid or the pterygoid without cranial nerve (CN) involvement.

METHODS AND MATERIALS

We retrospectively reviewed the clinical findings, radiological findings, and treatment outcome in 64 patients with Stage T4 NPC, diagnosed according to the American Joint Committee on Cancer 4th edition criteria. The median follow-up was 34 months (range, 3-118 months). Statistical analyses were performed using the chi-square test, the Kaplan-Meier method, and the log-rank test.

RESULTS

Local control was achieved in 19 (46%) of 41 patients with CN deficits and 18 (78%) of 23 patients without CN deficits (p = 0.01). Overall 5-year survival with and without CN deficits was 25% and 58%, respectively (p = 0.01). When the 16 patients with minimal bone disease were compared to the remaining 48 patients, there were significant differences in local control rates (87% vs. 48%, p = 0. 006) and 5-year survival rates (68% vs. 28%, p = 0.008).

CONCLUSION

Among patients with Stage T4 NPC, a subgroup of patients with only minimal bone disease may have a more favorable prognosis, which may have a considerable bearing on our approach to this patient group.

Epstein-Barr virus early ribonucleic acids as a diagnostic adjunct for relapsed metastatic tumors in patients with cured primary undifferentiated nasopharyngeal carcinoma

PURPOSE

Epstein-Barr virus (EBV) has been consistently shown to be associated with undifferentiated nasopharyngeal carcinoma (NPC). In this article, the authors attempt to detect Epstein-Barr virus in distant relapsed metastatic sites in undifferentiated NPC patients with cured primary cancer.

MATERIALS AND METHODS

In situ hybridization (ISH) technique is a reliable method to detect EBV early RNAs (EBERs) within NPC cells. We used a nonisotopical ISH technique to examine the presence of EBERs in paraffin-embedded tissues obtained from 1 paired specimen of primary NPC and its metastatic counterpart at liver and 2 metastatic specimens of retroperitoneal lymph nodes and bone.

RESULTS

All the primary lesions and the metastatic tumors of NPC with undifferentiated histology contained EBERs that could be clearly detected in the nuclei of cancer cells.

CONCLUSIONS

This article shows that EBERs can be successfully detected in cells of the distant relapsed metastatic sites. These results suggest that this nonisotopical ISH method of EBERs can be potentially used to diagnose NPC patients developing distant relapsed metastatic lesions with cured primary cancer early. It can offer quick information as to institute suitable salvage chemotherapy for these patients.

Long-term disease-free survivors in metastatic undifferentiated carcinoma of nasopharyngeal type

PURPOSE

To review incidence and analyze profile of long-term complete responders among patients with undifferentiated carcinoma of nasopharyngeal type (UCNT) treated at a single institution.

PATIENTS AND METHODS

We present a cohort of 20 long-term unmaintained complete responders to chemotherapy for metastatic UCNT treated at the Institut Gustave Roussy between April 1978 and November 1996. A patient was considered a long-term survivor if he or she was disease-free for more than 36 months without treatment after obtaining a complete response by chemotherapy. Patient characteristics were as follows: sex, 17 men and three women; median age, 28 years (range, 9 to 62 years); median World Health Organization performance status, 1; and initial tumor-node-metastasis stage (International Union Against Cancer-American Joint Committee on Cancer, 1987) of T3 to T4, 60%, and of N2b to N3, 75%. Epstein-Barr virus serology was characteristic in 19 patients. Of 16 pretreated patients, 11 were pretreated by radiotherapy alone and five by chemotherapy and radiotherapy. Thirteen patients had metastatic relapses of locally controlled UCNT. Tumor sites were bone in 15 patients, lung in four, and liver (biopsy-proven) in two. Chemotherapy included the following: cisplatin, bleomycin, and fluorouracil in five patients; bleomycin, epirubicin, and cisplatin in seven patients; fluorouracil, mitomycin, epirubicin, and cisplatin in four patients; and fluorouracil, bleomycin, epirubicin, and cisplatin in one patient. Three patients were treated with platinum-based regimens before 1985. Patients received a median of six cycles (range, three to 13). Thirteen patients with bone metastases received consolidating radiotherapy.

RESULTS

As of June 1999, 14 of 20 patients were still alive with no evidence of disease after treatment (disease-free survival time, 82+ to 190+ months), three patients died of other causes while in complete response at 61, 109, and 208 months after treatment, and three patients died of disease at 42, 89, and 115 months after treatment. Long-term complete responses were obtained in both bone and visceral disease.

CONCLUSION

Our data support a curative role for chemotherapy in metastatic UCNT and are a major incentive to continue research for better combinations to increase the percentage of patients with metastatic UCNT who attain complete responses and long-term survival.

Locally recurrent nasopharyngeal carcinoma

PURPOSE

To assess the outcome of and determine prognostic factors for locally recurrent nasopharyngeal carcinoma (NPC) in patients treated with a second course of radiotherapy (RT).

MATERIALS AND METHODS

From 1982 to 1995, 186 NPC patients, who had initially been treated in the Department of Radiation Oncology, Chang Gung Memorial Hospital-Linkou, developed local recurrence in the nasopharynx and were re-treated with RT (>/=20 Gy). The time from the initial RT to re-treatment ranged from 8 to 136 months (median: 23 months). All patients were treated with external RT and conformal radiotherapy was used in 35 patients after 1993. Fifteen received radiosurgery as a boost treatment. The RT dose at the nasopharyngeal tumor area ranged from 20 to 67.2 Gy (median 50 Gy). Eighty-two patients received one to eight courses of cisplatin-based chemotherapy in addition to RT.

RESULTS

The 1-, 3- and 5-year survival was 54.9, 22. 1 and 12.4%, respectively. Patients whose tumor relapsed later than 2 years after the first treatment had a better survival than those with earlier relapse (3-year survival: 30.1 vs. 10.8%; P=0.015), but the difference became insignificant in patients who received >/=50 Gy. Patients without evidence of intracranial invasion or cranial nerve palsy had better survival than those with such lesions (3-year survival: 30.9 vs. 3.7%; P=0.006). A re-treatment dose >/=50 Gy yielded better survival (3-year survival: 22.8 vs. 18.5%; P=0.003). Addition use of radiosurgery may improve survival. The use of chemotherapy did not improve survival. Conformal radiotherapy resulted in significantly fewer severe complications than conventional RT.

CONCLUSIONS

A repeat course of RT for locally recurrent NPC successfully prolongs survival in a significant number of patients. Intracranial invasion and/or cranial nerve palsy and re-treatment dose affect the prognosis, with a dose of >/=50 Gy significantly improving survival. Radiosurgery boost may also improve survival. Our preliminary data indicates that conformal radiotherapy may decrease the severity of radiation-induced complications. However; longer follow-up and larger sample size is necessary to document the findings.

Prognostic features and treatment outcome in locoregionally advanced nasopharyngeal carcinoma following concurrent chemotherapy and radiotherapy

PURPOSE

Concurrent chemotherapy and radiotherapy (CCRT) are effective in treatment of locoregionally advanced nasopharyngeal carcinoma (NPC). However, the prognostic factors after CCRT have not been evaluated. We therefore attempt to evaluate factors that influence treatment outcomes following CCRT.

METHODS AND MATERIALS

Seventy-four (5 in stage III and 69 in stage IV) patients with locoregionally advanced NPC were treated with CCRT. Radiotherapy was delivered either at 2 Gray (Gy) per fraction per day up to 70 Gy or 1.2 Gy, 2 fractions per day, up to 74.4 Gy. Concurrent chemotherapy consisted of cisplatin and 5-fluorouracil. Cox proportional-hazards model was used to analyze the prognostic factors which included age, gender, pathologic type, T, N, lactate dehydrogenase (LDH), and infiltration of the clivus.

RESULTS

The primary tumor control rate at 3 years was 96.7% (95% confidence interval [CI]: 92.5-100), distant metastasis-free survival 81.1% (95% CI: 70.6-91.6), disease-free survival 77.0% (95% CI: 65.3-88.7), and overall survival 79.8% (95% CI: 69.2-90.4) with a median follow-up interval of 29 months (range 15-74 months). Cox proportional-hazards model revealed that infiltration of the clivus and serum level of LDH before treatment were the most two important factors that predict distant metastases. Infiltration of the clivus and the serum LDH level greater than 410 U/L were strongly associated with distant metastasis-free survival (p = 0.0004 and p = 0.0002, respectively). When these two risk factors were considered together, no distant metastasis was observed in 40 patients with both intact clivus and LDH < or = 410 U/L. On the contrary, 13 of the remaining 34 patients with at least one risk factor developed distant metastasis (p = 0.0001).

CONCLUSION

Our study demonstrates that CCRT can improve the primary tumor control of 96.7% and disease-free survival of 77.0% at 3-year follow-up. Distant metastasis, however, is the major cause of failure. Infiltration of the clivus by the tumor and LDH greater than 410 U/L are the two independent and useful prognostic factors in patients with locoregionally advanced NPC who were treated with CCRT. Good- and poor-risk patients can be distinguished by virtue of their having both conditions.

Nasopharyngeal Carcinoma: Evidence for Improved Survival with Combined Chemoradiation

Radiation therapy has been the traditional treatment for nasopharyngeal carcinoma. Patients with advanced disease have a higher rate of locoregional as well as distant metastases, which has warranted the addition of chemotherapy in an attempt to improve survival. This retrospective study was designed to determine the absolute survival of patients with nasopharyngeal cancer treated with radiation alone, compared to that of patients receiving concurrent chemoradiation. Between December 1975 and December 1993 eight patients were treated with radiotherapy alone and 14 patients were treated with concurrent chemoradiation using 5-fluorouracil and cisplatin. Analysis of Kaplan-Meier cumulative absolute survival plots revealed that patients receiving chemoradiation survived longer than those receiving radiation alone (p=0.0321). Patients with lymphoepithelioma, as opposed to squamous cell carcinoma, and patients younger than 30 years were also found to have longer survival, although these differences were not statistically significant (p=0.0913 and p=0.04044, respectively).

Early stage nasopharyngeal carcinoma: radiotherapy dose and time factors in tumor control

OBJECTIVE

To evaluate radiotherapy dose and length of treatment in the control of early stage nasopharyngeal carcinoma (NPC) treated with a combination of external radiotherapy and brachytherapy,

MATERIALS & METHODS

We reviewed the records of 133 patients with early stage nasopharyngeal carcinoma (stage I or II, AJC/UICC staging system) who received definitive radiotherapy in Chang Gung Memorial Hospital from 1979 to 1991. The median follow-up time was 7.1 years with a minimum of 2 years. All patients were treated with megavoltage external radiotherapy to the nasopharynx area (63-72 Gy) followed by high dose rate intracavitary brachytherapy (5-16.5 Gy in one to three fractions, spaced 1-2 weeks apart). The median total dose and time of irradiation was 75 Gy (69.8-81.4 Gy) and 11.6 weeks (7.8-20 weeks) respectively. Survival analysis was used to examine the effect of several variables on prognosis.

RESULTS

The 5-year rates were 86.4% for local control, 84.7% for disease free survival, 88.5% for actuarial survival and 84.2% for overall survival. The treatment group (combination of time and dose of irradiation) was the most important prognostic factor according to Cox's proportional hazard model. Patients receiving radiation at a total dose of < or = 75 Gy completed in < 12 weeks showed the best prognosis.

CONCLUSION

Treatment time and total treatment dose are both important factors in treating early stage NPC. Decreasing the total radiation time to < 12 weeks and not exceeding a radiation dose of 75 Gy gave the best results.

Evaluation of cervical nodal necrosis in nasopharyngeal carcinoma by computed tomography: incidence and prognostic significance

PURPOSE

The purpose was to study the prognostic value of contrast-enhanced computed tomography (CT) nodal necrosis in nasopharyngeal carcinoma.

PATIENTS AND METHODS

One hundred sixty-one patients with newly diagnosed nasopharyngeal carcinoma and nodal metastases were reviewed. Forty patients also received cisplatin-based neoadjuvant chemotherapy in addition to radiotherapy. Nodal necrosis was defined as presence of hypodense areas in more than 33% of the node. Nodal response rate to chemotherapy, overall nodal control rate, local control rate, distant failure rate, overall relapse-free survival rate, and overall and cause-specific survival rates were compared between patients with and without nodal necrosis. Multivariate analysis was also performed.

RESULTS

The incidence of nodal necrosis was 22.9%. Overall nodal response rates to chemotherapy were 88.9% (8/9) in patients with nodal necrosis and 74.2% (23/31) in those without. No significant differences in nodal control rate, local control rate, distant failure rate, and overall and cause-specific survival rates were found. Five-year overall relapse-free survival rate was lower in patients with cervical nodal necrosis (36%) as compared with those without (53%, p = .04). Multivariate analysis, however, did not confirm cervical nodal necrosis to be an independent prognostic factor.

CONCLUSIONS

Presence of nodal necrosis in nasopharyngeal carcinoma does not affect nodal response to chemotherapy and nodal control by radiotherapy with or without chemotherapy. Cervical nodal necrosis does not appear to be an independent factor in predicting treatment outcome. Further studies to correlate nodal density with oxygenation status as well as tumor cell kinetics are warranted.

Prognostic value of paranasopharyngeal extension of nasopharyngeal carcinoma. A significant factor in local control and distant metastasis

BACKGROUND

This study was conducted to evaluate the prognostic value of paranasopharyngeal extension in local control and distant metastasis in patients with nasopharyngeal carcinoma.

METHODS

Three hundred and sixty-four patients with newly diagnosed nasopharyngeal carcinoma without distant metastasis were reviewed. Patients were staged according to Ho's staging system. Using a semiquantitative method, tumor extension into the paranasopharyngeal space was graded as: 0: no extension; 1: extension to the retrostyloid space; 2: extension to the prestyloid space; and 3: extension to the anterior part of the masticator space. All patients received radiotherapy as primary treatment. Median follow-up time was 45 months (range, 4.7 to 76.5 months). Relapse free, local relapse free, and distant metastasis free survival were estimated using the Kaplan-Meier method. Cox regression was also performed to adjust for prognostic factors.

RESULTS

The incidence of paranasopharyngeal extension was high (72.5%). Of these patients, 65.5% had Grade 2 or 3 extension. The 5-year relapse free survival rates for Grade 0, 1, 2, and 3 extension were 76%, 70%, 46%, and 43%, respectively. The main difference was between Grade 0/1 and Grade 2/3 extension, the latter having a lower 5-year local control rate (86% in Grade 0/1 vs. 72% in Grade 2/3; P < 0.0001) and distant metastasis free survival rate (87% in Grade 0/1 vs. 68% in Grade 2/3; P = 0.0002). Multivariate analysis showed that Grade 2/3 paranasopharyngeal extension was an independent factor in predicting overall relapse, local relapse, and distant metastasis. Advanced T classification (T3) was another independent factor in predicting overall and local relapse, whereas advanced N classification (N3) was another independent factor in predicting overall relapse and distant metastasis.

CONCLUSIONS

Extensive paranasopharyngeal extension (Grade 2/3) was an independent prognostic factor associated with poorer treatment outcome, both in local control and distant metastasis. Ho's T2 disease should be further subclassified into T2a and T2b, which include Grade 0/1 and Grade 2/3 paranasopharyngeal disease, respectively.

Expression of EBER1 in primary and metastatic nasopharyngeal carcinoma tissues using in situ hybridization. A correlation with WHO histologic subtypes

BACKGROUND

The association of Epstein-Barr virus (EBV) with nasopharyngeal carcinoma (NPC) is well documented. Previous studies reported abundant expression of EBER1 in primary NPC and tumors metastatic to lymph nodes. However, a large series of case studies correlating World Health Organization (WHO) histologic subtypes with EBER1 is needed.

METHODS

The authors applied the EBER1 in situ hybridization to investigate the expression of EBER1 in 140 primary NPCs, 11 metastatic tumors to lymph nodes, 6 metastatic tumors to bone marrow, and 2 metastatic tumors to the liver. All 19 metastatic tumors had paired specimens from their primary NPCs for comparison. The in situ hybridization method was performed on paraffin embedded tissues by using polymerase chain reaction-derived, digoxigenin-labelled EBER1 DNA probes.

RESULTS

The EBER1 signal was identified in nuclei of malignant epithelial cells in 135 of 140 (96.4%) primary NPCs, including 4 of 5 (80%) WHO-I histologic subtypes, 71 of 73 (97.3%) WHO-II histologic subtypes, and 60 of 62 (96.8%) WHO-III histologic subtypes (P > 0.05). However, the positive hybridization signal in WHO-I NPC was less in proportion to malignant cells, usually limited to basal cells, than in other histologic types of NPC. In 10 of 11 specimens with metastases to the lymph nodes, hybridization was always limited to the malignant cells and not associated with lymphocytes. All 10 paired primary NPCs also demonstrated positive EBER1 hybridization. Only one paired specimen showed negative EBER1 in primary NPC and a metastases to a lymph node. Eight distant metastases, all EBER1-positive in their primary NPC, also demonstrated positive EBER1 hybridization signals in the malignant cells. The proportion of EBER1 positivity in metastatic NPC is higher than that in primary lesions as observed in paired specimens from the same patient.

CONCLUSIONS

Because of abundant expression of EBER1 in primary NPC as well as in metastatic malignant cells, it is recommended that EBER1 in situ hybridization be performed on routinely processed specimens whenever NPC is suspected.

Head and neck cancer

This synthesis of the literature on radiotherapy for head and neck cancer is based on 424 scientific articles, including 3 meta-analyses, 38 randomized studies, 45 prospective studies, and 246 retrospective studies. These studies involve 79174 patients. The literature review shows that radiotherapy, either alone or in combination with surgery, plays an essential role in treating head and neck cancers. When tumors are localized, many tumor patients can be cured by radiotherapy alone and thereby maintain full organ function (1, 2). Current technical advancements in radiotherapy offer the potential for better local tumor control with lower morbidity (3). This, however, will require more sophisticated dose planning resources. To further improve treatment results for advanced tumors, other fractionation schedules, mainly hyperfractionation, should be introduced (5). This mainly increases the demands on staff resources for radiotherapy. The combination of radiotherapy and chemotherapy should be subjected to further controlled studies involving a sufficiently large number of patients (4, 5). Interstitial treatment (in the hands of experienced radiotherapists) yields good results for selected cancers. The method should be more generally accessible in Sweden. Intraoperative radiotherapy should be targeted for further study and development.

Impact of changes in the treatment of nasopharyngeal carcinoma: an experience of 30 years

Two hundred and twenty-eight patients with nasopharyngeal carcinoma were treated in a single institution in a 31-year period. Overall survival (OS), disease-free survival (DFS), and complete response (CR) rates were analyzed. In addition, survival and control rates from 1960 to 1975 and from 1976 to 1991 were evaluated. In the latter group, a comparative study was performed between patients treated with neoadjuvant chemotherapy (NCT) before radiotherapy (RT) (45) and patients treated with radiotherapy alone (45). OS at 5 and 10 years were 42 and 34%, and DFS rates were 35 and 30%, respectively. CR was achieved in 184 patients (81%). Tumor progression and survival were strongly associated with T-category. Use of fashioned blocks, age and T-category were the most important factors influencing survival in a multivariate analysis. In the patients treated with NCT, rates of CR and OS were not significantly different when compared with the concurrent RT alone group. Ninety-nine patients had recurrence (54%) and 58 received rescue treatment. Modern radiotherapy techniques have greatly assisted in the improvement of tumor control rates. Chemotherapy must be further evaluated and new treatments for relapsed patients are needed.

Iatrogenic Pneumocephalus in a Man with Undifferentiated Nasopharyngeal Carcinoma. A Case Report

A case of pneumocephalus in a 45-year-old male with undifferentiated rhinopharyngeal carcinoma is described. The patient was initially subjected to radiotherapy and then to transmaxillary resection and a second course of stereotactic radiotherapy for recurrent disease. Lastly, the patient was treated with chemotherapy because of local-regional disease progression. After two cycles of cisplatin, adriablastine and bleomycin, the patient suddenly entered in coma. Cerebral CT scan evidenced the presence of air in the frontal and lateral cornua, in the subarachnoid space of the base cisternae extending to the 7th cervical vertebra. After 8 months of a clinical stationary condition, the patient died. The various treatments used are critically reviewed, and modern therapeutic approaches for the neoplasm and the toxicity involved are discussed. We conclude that in nasopharyngeal carcinoma, for patients who relapse after radiotherapy, successive local-regional therapies (surgery, re-irradation) should be carefully evaluated to avoid demolishing treatments, which are burdened with severe side effects that might influence the quality of life with only slight improvement of overall survival. Furthermore, the presence of persistant aqueous rhinorrhea in these patients should be carefully evaluated, because it could be an early symptom of a cerebrospinal fluid leak.

Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and therapeutic aspects

Undifferentiated carcinoma of the nasopharynx (UCNT) is a particular head and neck epidermoid lineage tumor related to the Epstein Barr Virus (EBV). It has geographically selective endemic epidemiologic features, without relation to external carcinogens. Its systemic agressiveness is the source of most disease-related demises, because radiotherapy achieves excellent local control and a significant percentage of cure in patients with exclusive locoregional disease. Difference in the staying systems currently in use, the recent changes in imaging and radiotherapy technology, and the lack of distinction between UCNT and squamous cell carcinoma (SCC) of the nasopharynx in Western literature reports make for some difficulty in therapeutic results evaluation when analyzing available literature. Its chemosensitivity is a relatively recent acknowledged fact, and its use in metastatic patients results in a high percentage of objective responses, many of long duration. Neoadjuvant cisplatin-based chemotherapy seems to be of benefit, but outstanding controversies in this regard will be soon answered through ongoing phase III trials. After a review of the current literature of all the above-mentioned aspects of this fascinating nosologic entity, our own experience, both in metastatic and locoregional disease patients is analyzed.

Radioresponsiveness of human glioma, sarcoma, and breast cancer spheroids depends on tumor differentiation

PURPOSE

Differences in the intrinsic radiosensitivity within and between different tumor classes have been noticed for human tumor cell lines using the clonogenic assay. By far, most of the cell lines studied up to now were derived from poorly differentiated tumors. In this study, the influence of tumor differentiation on the radiation doses necessary to control 50% of small oxic spheroids (SCD50) was determined. Evidence of a distinct dependence of radioresponsiveness on tumor progression provides a background for an investigation of the underlying mechanisms.

METHODS AND MATERIALS

Spheroids were aggregated from 1000-1500 cells in agarose coated 24 multi-well plates. Their diameters ranged from 156 to 405 microns, depending on the cell line. Spheroids were irradiated with graded 60Co single doses using spheroid control as end point and a minimum follow-up period of 3 months.

RESULTS

Cell lines from three low grade gliomas and 10 malignant gliomas were studied in the spheroid control assay. The group mean SCD50 values were 6.1 +/- 1.6 Gy and 13.1 +/- 3.3 Gy, respectively. Four cell lines from grade 2 soft tissue sarcomas had a mean SCD50 value of 6.2 +/- 0.5 Gy and one undifferentiated sarcoma line of 11.0 Gy. Three well-differentiated breast cancer lines expressed the cell adhesion molecule E-cadherin, had an epithelioid morphology in monolayer culture, were estrogen receptor positive or contact inhibited in multicellular spheroids. Two undifferentiated breast cancer lines had a fibroblastoid morphology and were marker negative. The mean SCD50 value of the former was 10.5 +/- 1.0 Gy while that of the undifferentiated lines was 14.8 +/- 2.8 Gy. Analysis of variance revealed a significant effect of the tumor type as well as the grade of dedifferentiation on the SCD50 after irradiation with one fraction or 2Gy/fraction. The surviving fractions at 2 Gy (SF2), obtained from the spheroid control rates after different fractionation schedules by approximation of the linear quadratic model assuming Poisson statistics were significantly dependent on tumor type (p = 0.001, ANOVA F-test) but not on tumor differentiation (p = 0.27). The alpha/beta ratios did not depend on tumor type (p = 0.08, ANOVA F-Test) but significantly increased with the grade of tumor cell dedifferentiation (p = 0.03).

CONCLUSION

The spheroid model is suitable for measuring the radioresponsiveness of differentiated cell lines with very low colony forming efficiencies. Tumor cell differentiation is an important factor for the radioresponsiveness and recovery capacity of human tumor cells.

Synchronous radiotherapy and chemotherapy in the treatment of nasopharyngeal carcinoma

PURPOSE

Because of the high rates of local tumor control obtained by combining moderate doses of external beam radiotherapy and synchronous 5-fluorouracil/mitomycin C chemotherapy in the treatment of squamous and basiloid cancers of the anal canal, we chose to investigate this regimen for nasopharyngeal cancer which shows significant local and distant failure rates after treatment with radiotherapy alone.

METHODS AND MATERIALS

Between 1983 and 1990, 43 patients with previously untreated squamous cell and undifferentiated nasopharyngeal cancer, without evidence of distant metastases at diagnosis were treated with radical radiotherapy and concurrent chemotherapy using mitomycin C (10 mg/m2 i.v. day 1 of radiotherapy) and 5-fluorouracil (1000 mg/m2 continuous i.v. infusion days 1-4 of radiotherapy and repeated at least 28 days later). Ninety-one percent of cases had Stage IV tumors and 93% had clinically involved regional lymph nodes.

RESULTS

Actuarial rates of survival, local control, regional nodal control and distant metastases at 5 years were 37%, 71%, 94%, and 53%. Grade 3 or 4 skin and mucosal reactions occurred in 30% and 34% of patients, respectively. Only one patient developed greater than Grade 2 myelosuppression and he died of overwhelming sepsis. A second patient died of malnutrition 4 months after treatment giving a 5% incidence of treatment-related mortality. Nine percent of patients developed significant late complications of treatment.

CONCLUSION

Despite the morbidity observed, the treatment outcome is not obviously superior to that reported for radiotherapy as a single modality of treatment.

Nasopharyngeal carcinoma: a 15-year retrospective study

Malignancy in the nasopharynx, although uncommon, is potentially devastating because of the anatomy of the region and benign early symptoms, which result in infrequent early diagnosis. High-dose radiation therapy, with fields including the oral structures, is the treatment of choice and may result in significant oral complications. This paper reviews 39 cases of nasopharyngeal carcinoma diagnosed at the University of North Carolina Hospitals over a 15-year period. Patient demographics, histopathology, presenting signs and symptoms, stage at diagnosis, possible risk factors, treatment modalities, survival, side-effects of therapy, and dental intervention are reported.

Prognostic factors in patients with nasopharyngeal carcinoma

From 1971 to 1985 a total of 122 patients with non-distant metastatic nasopharyngeal carcinoma were treated at the Norwegian Radium Hospital with radiation doses that increased from 50 Gy (at 2 Gy/fractions) to 70 Gy (at 2 Gy/fractions) during the treatment period. Possible relationship between the increase in dose and survival time was investigated. The median cancer-specific survival time was 50 months, and the median crude survival time 38 months. No correlation was found between radiation dose and survival time. In a multivariate analysis histology was found to be the most important prognostic factor for survival with a relative risk of death from cancer of 3.4 and 3.2 for non-keratinizing carcinoma and squamous cell carcinoma respectively compared with undifferentiated carcinoma. When assessed in terms of N category the relative death risk for N2/N3 was 2.1 compared to N0/N1.

Recurrent locally advanced nasopharyngeal carcinoma treated with heavy charged particle irradiation

Between June 1981 and May 1990, 11 patients with recurrent locally advanced nasopharyngeal carcinoma were treated with heavy charged particle radiation at Lawrence Berkeley Laboratory. All patients had previously undergone full course radiotherapy to a median dose of 70.2 Gy [range 61-81 Gy]. Median time to recurrence was 18.2 months. At the time of heavy charged particle radiotherapy treatment, all had evidence of invasion of the base of skull and 7 of 11 had cranial nerve deficits. None of the patients were candidates for brachytherapy because of tumor extent or poor geometry. The tumor histology was squamous cell carcinoma in 10 patients and lymphoepithelioma in one patient. Ten of the 11 patients had received chemotherapy prior to re-irradiation. The heavy charged particle tumor dose delivered ranged from 31.80 GyE to 62.30 GyE (average 50.25 GyE, median 50 GyE). Local control was achieved in 45%. Median survival was 42 months. Actuarial survival was 59% at 3 years and 31% at 5 years (Kaplan-Meier). There were no fatal complications. The results in treating locally advanced recurrent nasopharyngeal carcinoma with heavy charged particles appear superior to those reported by others using photon therapy.